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Leadership is about being grounded by our principles rooted in the values and practices of our culture.

—Norma Rabbitskin, 2017

Introduction

Being an effective leader involves developing skills, knowledge, and attitudes that foster good working relationships with Indigenous communities, leaders, and individuals. Nichols (2004) points out that nursing schools prepare people to become nurse leaders, but do not prepare people to become leaders “in the Indian way” (p. 177). Other researchers (Julien, Wright, & Zinni, 2010) recognize that current leadership theories often reflect cultural ideas of Western societies and do not take into account Indigenous worldviews. This chapter presents selected Indigenous worldviews and challenges students to compare their own understandings of Indigenous culture with those presented in the chapter. In addition, recommendations and examples are provided on how leaders can negotiate and make sense of the different cultural worlds they work with and dwell in. While this chapter discusses Indigenous perspectives, it is important to recognize that Indigenous cultures in Canada are extremely diverse, not only from one treaty territory to the next, but also among neighbouring communities. However, there are still common norms that apply to many Indigenous communities. In this chapter, the authors will share selected stories and their knowledge of nursing leadership with the intention of providing students with a better understanding of how to work in their roles as nurse leaders alongside Indigenous leadership.

 

3.1 A Glance at the Literature

There are a number of differences between Indigenous and other types of leadership styles. One such example is the use of traditional imagery and storytelling (Julien et al., 2010; Nichols, 2004). Lessons are taught through stories and also have a connection with the land and Indigenous identity (Nichols, 2004; Wolfgramm, Spiller, & Voyageur, 2016).

 

 

Nichols (2004) conducted focus groups with Native American nurse leaders and found that the point of reference for the Indigenous nurse leaders were the individuals they worked with: their families and tribal communities. The Indigenous nurse leaders were tied closely to their communities and their view of leadership was about leading the organization and community as a whole.

Felicity (1999) and Nichols (2004) also reinforced the holistic view of Indigenous leadership and leaders’ concerns for the community. Julien and colleagues (2010) took this notion of holistic leadership a step further by describing spirituality as a central element of Indigenous leaders’ practices and beliefs:

One respondent noted that, while his non-Aboriginal colleagues had a tendency to focus on processes and were greatly motivated by outcomes that were purely profit-driven, he felt his work was a spiritual endeavor. He expressed that “the work we do—it’s not about education, it’s not about research—it’s about spirituality; the other things are just part of the whole process.” (p. 119–120)

Julien and colleagues (2010) also described time elements that Indigenous leaders value. The knowledge that departed Elders had shared needed to be considered, built upon, and valued. It was also important to consider the impact that resolutions would make on future generations (i.e., seven generations into the future).

Nurse leaders need to consider the population being served, as explained by nursing theorist Madeleine Leininger. Her transcultural nursing theory encompasses “the concept of cultural competence, that is, the nurse’s ability to incorporate considerations of an individual’s cultural background into nursing practice [and leadership]” (Johnson & Webber, 2015, p. 207).

 

3.2 Living within the Community: Gaining an Understanding of Indigenous Worldview and Leadership Structures

Section 3.2 “Living within the Community,” as told by Norma Rabbitskin of Big River First Nation, is based on Traditional Knowledge. Norma is a Knowledge Keeper of the ways of the Big River First Nation. This Traditional Knowledge IS NOT licensed under Creative Commons Attribution 4.0 International License (CC BY). Please respect the Protocol of Indigenous Traditional Knowledge translation and contact Norma Rabbitskin at the Sturgeon Lake Health Centre if you wish to use this content further.

Entering into a healing profession came naturally for Norma Rabbitskin. She is a fluent Cree speaker from Big River First Nation. Norma’s work experience includes over 29 years as an RN, with the majority of her career within First Nations communities. In the following section of this chapter, she passes on her various nursing knowledge and the teachings instilled by her family, ceremonialists, knowledge keepers, and various leaders. Norma shares her experience working within First Nations communities and the essential leadership skills required to oversee a nursing program.

First and foremost, as First Nations people we acknowledge the Creator and the principles of creation. We uphold natural law, our ways of being, and how to live in harmony on askîy pimâtisiwin (Earth Life). Knowledge is transferred to each generation through the oral tradition and is renewed in ceremony starting with the creation story. Culture is a way of life; this maintains and preserves the sacredness of life and teaches us how to live in harmony within the Circle of Life and with all relations on this Earth. Keytayak (old ones) role modelled a gentle integrative process where every individual envisions their full capacity and well-being to achieve their potential.

Holistic Model of Leadership Using the Circle of Life Teachings

As nurse leaders, we need to look at ways to be effective in empowering our clients and families and we need to understand what healthiness looks like for a First Nations community. We do this by taking part in experiential learning regarding Indigenous culture and worldview.

Circle of Life Teachings

Our Elders tell us that the human maturational and learning process is not linear, but rather that life is a circle, reminding us that wherever we go and whatever we experience, the self is still present, bringing us home to ourselves, families, and community with all that we have become during our learning process. Teachings of natural laws create a foundation for healing and understanding the interconnectedness of our Indigenous development (mentally, emotionally, physically, and spiritually) and our human relations (family, community). The Circle of Life teachings represent a way of life that promotes health and wellness. This approach reflects a holistic and earth-centred philosophy of life and healing that is not often found in Western approaches to health. Elders say that the Circle of Life teaches us about interconnectedness: when you do your own healing as an individual, you help your family heal. When families begin to change or heal, then communities also change. As our communities come into wellness, our people will heal. When planning or developing programs, we need to consider everyone, as in the holistic view: the individual, family, and community.

Individual

Our Elders teach that all aspects of a person—the physical, the mental, the emotional, and the spiritual—must be addressed, and in balance, in order to promote holistic health and healing. Good health implies an optimum state of well-being in all four areas. Well-being flows from maintaining balance and harmony between all of these areas and with nature. A holistic approach to health also takes into account the importance of culture, language, and tradition. Elders are sought for emotional guidance.

Mental health refers to our thinking and thoughts including knowledge, education, reading, and learning about chronic disease. Individuals learn to practise self-discipline, make healthy decisions, problem solve, and create change. Optimal mental health results in healthy choices.

Emotional health refers to identification and acceptance of feelings—fear, anger, confusion, sadness, depression, loneliness, worry, and anxiety. Learning to express feelings appropriately with effective coping skills that help maintain balance leads to a sense of well-being during times of adversity. Optimal emotional health results in improved self-esteem, self-awareness, positivity, trust, honesty, and hope.

Physical health refers to caring for the body: eating a healthy, balanced diet, controlling one’s weight, exercising and moving daily, and resting. Individuals learn to develop healthy routines and avoid destructive habits such as tobacco misuse, drug use, and alcohol abuse. Self-care is achieved as individuals learn to take responsibility for their health, to be good and kind, and to love and respect themselves.

Spiritual health refers to seeking harmony with a higher power and finding purpose in life. By adopting values, individuals can then choose activities and behaviours that are consistent with them. Individuals seek Elders for spiritual guidance and participate in sharing circles, healing circles, and talking circles. Optimal spiritual health is reflected in a life of prayer, faith, belief, hope, love, acceptance, forgiveness, and respect.

Health professionals today are actively engaged in identifying the attributes of health or wellness as defined by the people they serve. To be effective in empowering our clients, we as nurses need to understand what healthiness looks like for a First Nations community. One needs to be mindful of the population being served and the cultural healing practices being used. Historically, Indigenous communities have followed a holistic model that dictates a way of responding to ailments. For example, there are different health outcomes for clients:

• when using a wellness focus versus an illness focus;
• when working with a family versus an individual; or
• when taking a long-term versus an episodic perspective.

Family

Our greatest gift is our family. Elders teach us that the Creator gives us our kinship system, which is the place where all teachings are handed down from grandparents to parents and to children. Knowing this, each person in the family is responsible for maintaining the health and well-being of each other. In your role as a nurse, it is important to build a nurse–client and a nurse–family relationship, which become central to quality client and family holistic care. This relationship facilitates a positive experience built on communication and understanding of physical, emotional, mental, and spiritual needs, while also respecting client and family rights to make their own decisions. As nurses, we are facilitators for change who assist them in attaining their vision for health and well-being.

Working in Indigenous communities requires nurses to use critical thinking and nursing assessment skills. Integration of effective tools, such as the Family Assessment and Intervention Model, which builds “on the family’s strengths by helping the family identify its problem solving strategies” (Kaakinen et al., 2014, p. 92.), is essential. Use of this tool requires the nurse to develop knowledge about both the client and their family through completion of a family genogram (family tree). This is individualized care and demonstrates respect for the client and family.

Strong communication and interpersonal skills are critical aspects of quality nursing care in an Indigenous community. If nurses do not have these skills, they will contribute negatively to the already stressed situation of Indigenous clients and families. Another effective tool for Indigenous clients and families is the Family Systems Stressor–Strength Inventory. This is an assessment tool that guides “nurses working with families who are undergoing stressful health events . . . to build on the strengths of the family” (Kaakinen et al., 2014, p. 93).

As nurses, we need to develop interventions that lead to holistic care for our clients and their families based on a good assessment. Care of the individual is built upon a respectful and therapeutic relationship between the nurse and the individual and family. It is only by using critical reflection to examine our values and beliefs and our knowledge of family nursing that we can facilitate a shift in attitudes and develop a trusting therapeutic relationship with our clients and their families. To build a strong rapport we need to take the time to listen and schedule home visits, make telephone calls, and keep the family engaged. An essential component of clinic and community assessments includes inquiring about health concerns and asking clients how we can help them meet their goals.

Community

First Nations have accessed broader views of healthiness using cultural lenses and holistic paradigms that pay attention to the interconnecting modes of mind, body, and spirit. With such an inclusive perspective, the culture of beliefs, customs, and practices as foundations of Indigenous society in which the people are immersed, open up as sites for integrated and responsive services for people in community-based settings. Some ways of culture, as an example, such as valuing land as a site for health, relationship building, and developing strong focused minds through Indigenous ways of knowing are acknowledged as factors in building strong people, or as localized health determinants that are real. Assessing the state of health and well-being in communities would necessarily involve examining the community ethos that embodies the beliefs, values, and practices deemed essential for community vitality. (Willie Ermine, Indigenous Knowledge Keeper, personal communication, April 2017)

As a grandmother, and as one who has chosen a profession in nursing leadership, I appreciate how leadership decisions are made within an Indigenous community. A community foundation is shaped by the guidance provided by community knowledge keepers, healers, ceremonialists, leaders, and Elders. Through their examples I came to appreciate the full spectrum of service leadership. These pipe carriers, ceremonialists who dedicated their lives to maintaining medicine and cultural ways, assisted me in stepping seamlessly into a nurse leadership role. As well, my decision-making processes arose out of my Cree upbringing and this lived experience, and they are based on inclusivity, with full recognition that all life forms are sacred.

Within my worldview, decisions are made with the spirit of reciprocity, which is the backbone of my nehiyaw (Cree) worldview. In the spirit of reciprocity, we give before we take, and it is the true partnership of sharing of space and resources, of how we interact. I acknowledge the humanness of all people, that we are never perfect. I believe our ceremonies and traditional practices are the foundation supporting people to live out their responsibilities and to help others.

Fulfilling a nursing leadership role within Indigenous communities requires one to be aware of the co-existing leadership systems. The elected leadership, who adhere to terms of office set out by different levels of government, must answer to the people. I work in a First Nations community, located within Treaty 6 territory. This community has its own sovereign approach and the people control their own health care system. Decisions are voted on by chief and council and presented as Band Council Resolution (BCR), through a highly political process lead by elected members of the reserve. These men and women step into these elected roles because they want to serve their community by leading its members through a formal organized process. The protocols and ceremonies are in place to inspire individuals to work toward the well-being of the community.

Understanding the Indigenous leadership structures that exist within our diverse Indigenous communities begins by first creating a process of dialogue that engages in reciprocity, maintaining a balance of mutual coexistence. Respect is central to our lives. Our oral tradition as nehiyaw people exemplifies the values of how to live in balance and in harmony within natural law. This is truly land-based leadership. There are two main types of onikaniwak (for those who lead) within our Indigenous communities. They are: (1) service leadership, and (2) elected leadership of chief and council. Bear in mind, both types of onikaniwak are practised by the Elders and people, but through different approaches.

 

3.3 History of the Health Care System in Indigenous Communities

In the spirit and intent of treaty negotiations, the Indigenous people negotiated access to both “medicines” and “medical expertise needed to deal with new diseases” included in the Treaty 6 medicine chest clause to supply all that was required to maintain proper health (Office of the Treaty Commissioner, 2000). The federal government is responsible for supplying and maintaining health services for First Nations. Since the time of the treaties, these “medicines” have included Indian hospitals, medicine, doctors, examinations and treatment of the sick, x-rays, and medical technology.

Historically, relationships between Indigenous people and settler society have been characterized by a number of negative experiences and the two societies developed separately from one another. For the majority of Canadians, health care services are guaranteed by the Canada Health Act and provincial legislation. Indigenous people can access the same services but to differing extents.

In 1989, the National Health and Welfare and Treasury Board of Canada started work toward the transfer of health services for Indigenous communities from the federal to the community level. The transfer of health services is an administrative mechanism that shifts delivery of financial resources from the First Nations and Inuit Health Branch (FNIHB) to Indigenous communities for a select number of health programs. This health transfer supports Indigenous communities in exercising a higher level of governance over their community health care system and lobbying for change as required in the health system.

The goals and objectives of the health transfer policy were:

• to provide Indigenous people opportunities to become actively engaged in planning, administration, and delivery of on-reserve health care services, policy planning, and research;
• to improve health for Indigenous people;
• to ensure Indigenous people have the same quality of seamless care as the rest of Canadians;
• to enable communities to design health programs, establish services, and allocate funds according to community health priorities;
• to strengthen and enhance accountability of leaders to their members; and
• to ensure public health and safety are maintained through adherence to mandatory programs. (National Health and Welfare & Treasury Board of Canada, 1989; Smith & Lavoie, 2008)

The following table describes models of service delivery provided through a contribution agreement with Health Canada under FNIHB.

Table 3.3.1 Models of Health Service Delivery (Data source: Table based on material from Lavoie et al., 2005.)

Transferred Community	Integrated Communities	FNIHB–Controlled Community
Transferred public health programs are delivered at the community level or by Tribal Council. Financial accountability is the responsibility of the community or Tribal Council. Five-year funding is provided for programs. The public health programs are guided by: (1) a transfer implementation framework; (2) a community health plan; and (3) an evaluation plan.	FNIHB provides non-transferable programs. FNIHB provides semi-transfer of public health programs. Communities can hire their own nurses.	FNIHB delivers non-transferable public health programs to communities. FNIHB delivers second- and third-level health programs directly to communities. FNIHB provides policy and specialty health services. FNIHB allocates nursing staff.

The table above outlines the differences between the health care delivery systems that the communities may choose to adopt based on a community’s readiness, needs, and evaluation recommendations. This permits them to meet the changing health trends at the community level.

The community I work under is a fully transferred community, therefore the community delivers the following programs at the community level and some services are delivered by second- or third-level support:

• community health programs (health promotion and prevention)
• Community Primary Care
• communicable disease control and surveillance programs (Northern Intertribal Health Authority, third-level support)
• community immunization programs
• Environmental Public Health Program (Tribal Council, second-level support)
• National Native Alcohol and Drug Abuse Program (NNADAP) and
• Home and Community Care Program (semi-transferred)

Community-based services are delivered in the community by nurses and community health representatives, which includes addiction workers and maternal child care workers. Environmental health services are supplemented by environmental health officers at the second level of organization (Tribal Council) and are supported by the third level of organization (the health region or province).

The transferred community service delivery model is guided by the transfer implementation framework, which outlines how the services are to be delivered and evaluated. Communities follow a strict reporting criterion before funding is released, as outlined in the FNIHB’s contribution agreements documents. Provision of health services for the integrated delivery model differs significantly from the transferred community model and was approved in 1994 under separate Treasury Board authorities. An integrated model is understood as a step toward the full transfer model. Communities can select a range of community-based programs under a single contribution agreement that can be up to five years in length. Funding is based on community work plans and the community or Tribal Council must seek permission from FNIHB to make changes. The carry-over of funds is not allowed and any unspent funding must be send back.

FNIHB has a fiduciary responsibility (a legal duty to act for the benefit of the community) and is accountable for the overall health delivery system for people living on a reserve, a First Nations community. The National Treasury Board transfers money to the region to ensure the health needs of every Indigenous person is addressed. Today, FNIHB continues to monitor the quality of service delivery by First Nations communities to ensure adherence to contribution agreements. The type of health funding found in each community depends on the particular facility designation; these include: health office, health station, health centre, health centre with treatment, or nursing station. Each designation is differentiated by the type and scope of services it delivers. This is an ongoing concern for some communities since it affects the level of funding an organization can access.

 

3.4 Leadership Structures

Over the years since the health transfer system was introduced, there have been key lessons learned and identified by First Nations and Inuit people who continue today to address the gaps by advocating for equitable, seamless health care that honours treaty rights. First Nations communities work with organizations that support communities in carrying out policy and protect treaty rights. The Federation of Sovereign Indigenous Nations (FSIN) represents 74 First Nations in Saskatchewan, and the Assembly of First Nations (AFN) is the national representative organization of 630 First Nations in Canada. These organizations work with First Nations through their leaders to promote, protect, and implement the treaty promises in areas such as Indigenous and treaty rights, economic development, education, languages and literacy, health, housing, social development, justice, taxation, land claims, and environment, as well as an array of issues that are of common concern. First Nations communities fall under 50 culturally and linguisticly distinct groups dispersed across Canada. There are a number of other political entities that also represent the different First Nations populations at different levels, including local Band Councils, Tribal Councils, and provincial organizations.

The following table sets out the levels of leadership within the First Nations leadership structure and the responsibilities that fall under each level. As a nurse leader, it is important to understand First Nations leadership structures in order to know who has responsibility for areas that nurses may want to address.

Table 3.4.1 Levels of Leadership within the First Nations Leadership Structure

Responsible for the following to manage, maintain, and provide health care services:
First and second levels (First level – First Nations community; Second level – Tribal Council or organization of multiple communities)	Record management (including staff activity records) Administration system to hire and supervise staff Professional support Program design and delivery Program direction Program support Program evaluation Purchasing of educational materials Supervision of educators and professionals Advocacy Data collection and report preparation Development of program linkages and coordination to facilitate single source access to social programs for children and families Capacity building including training, education, community development, peer support, and networking Community-based research
Third level (Regional or provincial)	Maintenance of a working relationship with Health Canada, Service Canada, Indigenous and Northern Affairs Canada (INAC), and the Assembly of First Nations (AFN) Representation on regional, provincial, and national working and advisory groups Northern regional strategic planning for the North Data stewardship for partners as mandated Data collection and coordination with partners Development of program linkages and coordination to facilitate single source access to programs and services Capacity building including training, education, community development, peer support, and networking Program support, such as the distribution of relevant documents and information Program and clinical expertise Coordination of training Program evaluation and monitoring Research and evaluation
Fourth level (National)	Facilitation of research Maintenance of a working relationship among Health Canada, MSB (Medical Services Branch), AFN, the Inuit Tapiriit Kanatami, and INAC Coordination of National Steering Committee activities and follow-up to their direction Ongoing communication of information to First Nations on national developments Development of program standards for training and care Data analysis and report preparation from a national perspective National evaluation and accountability activities Facilitation of the development and implementation of programs

 

As a nurse leader working with Indigenous leaders and communities, it is important to refer to the First Nations Wholistic Policy and Planning Model (Reading, Kmetic, & Gideon, 2007), which was created to better understand the policy structure, planning, and interventions associated with performance indicators that are realistic for communities. This model attempts to capture the complexity of working with Indigenous communities from an Indigenous perspective. This model has the following key characteristics (p. 30):

• community at its core;
• four components of the Medicine Wheel (spiritual, physical, emotional, and mental);
• four cycles of the lifespan (child, youth, adult, and Elder);
• four key dimensions of First Nations self-government (self-government/jurisdiction, fiscal relationships/accountability, collective and individual rights, and capacity/negotiations);
• social determinants of health; and
• three components of social capital (bonding, bridging, and linkage).

 

3.5 Recommendations for Working with Indigenous Communities

Ethics and Research Guidelines

Indigenous communities and people have a history of being over-studied and “tokenized” when non-Indigenous people engage and elicit their help (Campbell, 2014; First Nations Centre, 2007). This has led research organizations such as the Canadian Institutes of Health Research (CIHR) (2007), Social Sciences and Humanities Research Council (2015), and the First Nations Centre (2007) to develop guidelines for anyone researching Indigenous people. The first set of principles developed by CIHR (2007) provide a collective set of guidelines to “assist researchers and institutions in carrying out ethical and culturally competent research involving Aboriginal people” (p. 259). According to Ramsden et al. (2017), the guidelines state:

engaging with FN communities is in Chapter 9 of the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans . . . where research projects involving First Nations, Inuit, and Metis peoples and their communities are to have a role in shaping and co-creating all research that affects them. (p. 2)

This certainly respects the autonomy of Indigenous clients, their families, and communities who participate in research opportunities (Campbell, 2014).

The First Nations Centre (2007) developed a set of principles referred to as OCAP (Ownership, Control, Access, and Possession). Ownership challenges the academic notion of intellectual property and describes the community ownership of data. The concept of control challenges the academic notion of control of the research process. The principles that guide community access and possession require that the community has full access to and possession of the research information. In leadership positions, it is important to understand how to apply these principles to work and initiatives involving Indigenous people.

 

In addition to the guidelines described above, researchers have identified the importance of issues that are raised while working with other cultures (Clandinin & Connelly, 2000; Ermine, 2007). Ermine (2007) discusses the importance of creating a respectful research relationship and asks researchers to consider the ethical space of engagement:

The “ethical space” is formed when two societies, with disparate worldviews, are poised to engage each other. It is the thought about diverse societies and the space in between them that contributes to the development of a framework for dialogue between human communities. The ethical space of engagement proposes a framework as a way of examining the diversity and positioning of Indigenous peoples and Western society in the pursuit of a relevant discussion on Indigenous legal issues and particularly to the fragile intersection of Indigenous law and Canadian legal systems. (p. 193)

He argues that researchers must examine the influence of Western perspectives on their understanding of the world and recognize that their perspectives often provide only one viewpoint. A broader examination of cultural, social, and political factors is important when working with and caring for Indigenous persons. It is essential for researchers to recognize and critique the historical relationships between Indigenous worldviews and Western thought (Barlow, 2009; Ermine, 2007; Patterson, Jackson, & Edwards, 2006).

 

Truth and Reconciliation Commission of Canada

It is well documented that Indigenous culture and identity has been lost as a direct result of residential schools and institutionalization (Adelson, 2000; Barlow, 2009; Comack, 2008; King, Smith, & Gracey, 2009; Laliberte et al., 2000; Truth and Reconciliation Commission of Canada, 2015). Adelson (2000) argues that if colonialism and neocolonialism created disenfranchisement and attempts to eradicate cultural history, then “reconstitution and reaffirmation of identity” (p. 30) may be what is needed to counteract those acts. The Truth and Reconciliation Commission of Canada (2015) offers a detailed document that provides not only a history of the effects of colonialism in Canada, but also a call for action to address the assimilation attempts on Canadian Indigenous people by churches and governments. The document provides “calls to action” to “redress the legacy of residential schools.”

 

Summary

Nurse leaders need to learn to work effectively within Indigenous communities and with Indigenous leaders. The first step is to be open and willing to understand Indigenous worldviews. This understanding requires nurses to acknowledge the history of Indigenous people in Canada and how the leadership and decision-making structures in Indigenous communities are unique. Finally, with an openness to working with Indigenous leaders and community members, nurses can build respectful, ethical, and meaningful relationships that will ultimately benefit the health of all people.

 

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